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As bariatricians, we have expert knowledge about the metabolic processes that are associated with

obesity and overweight and can provide solid recom-mendations for our patients to help them lose weight and improve their health. Yet, despite our medical expertise, we are often baffled as to how to help our patients make these recommended changes. We often think that if we give the patient informa-tion about their health and disease risks, they will be motivated to address them. In a few cases this is all it takes. So why is it that, despite being provided with a thorough medical assessment, specific recommenda-tions, and brilliant advice, most of our patients cannot adopt these suggestions? I have learned that providing information and ad-vice alone is usually not enough to help patients make the desired changes. The reality is that if it were as simple as knowing what to do and doing it, most of our patients would have already done so. Unfortunately behavior change is not that simple. It is a complex and often mysterious process. Given its complexity and mystery, I will share some concepts that can be integrated into bariatric treatment that will improve the odds that patients will lose weight, improve their health, and maintain these behaviors for the rest of their lives. I believe that patients need our guidance on the change process as much or more than they need our medical advice. During the first consultation I em-phasize that my goal is to help the patient make sus-tainablechange. By focusing on making long term change rather than achieving weight loss only, they have the best chance of reaching their health and weight goals. From the beginning of treatment I edu-cate patients about the complexity, pitfalls, and pro-cess of long-term behavior change. This gives them a cognitiveliferaft to help them anticipate and navigate through the often tumultuous experience of change. By knowing in advance that there will be challenges and derailments AND that you are a non-judgmental resource and support for them, your patients will be better able to navigate the messy process of change. One of the first topics I address is reframing what “success” is, and helping them move from the Holly-wood version of weight loss to a more realistic, health

focused expectation. Many of our patients are lifelong perfectionists. Perfectionists have well-developed inner critics who are very skilled at setting up rigid rules and regulations for losing weight, along with specific weight loss targets (i.e. lose five pounds every week for the next year) and then berate themselves for not perfectly following the rules or failing to reach their often unrealistic targets. Perfectionistic, self-critical tendencies often lead to black and white, all-or-nothing thinking. Some may be able to achieve perfection in the beginning but it is impossible for them to sustain it. We have all had patients who are 100% on track and somehow get derailed, only to continue being derailed for days, weeks, and even months, and seem unable to get back on track. Their underlying belief is, “If I can’t do it perfectly, I’m not going to do it at all.” When you think you have to do everything perfectly, it leaves very little room for learning and growth. Striving for perfection is immobilizing. By learning to toler-ate the messy gray zone, they will develop the self-awareness and skills that will help them get back on track much sooner than they will by using black and white thinking. One of the ways I combat perfectionistic thinking is to tell my patients that my clinical focus is to help them follow my recommendations in a way that is goodenough. Goodenough to 1) lose weight; 2) im-prove their health; and 3) learn the skills they need to manage their weight and health for the rest of their lives. I explain that mistakes or lapses are not an-noying events that interfere with them reaching their goals; they are one of the most important elements of the process. I tell them they will get strong by strug-gling and that I will be there to provide guidance and support. When discussing this concept, I use the ex-ample of a chick that pecks its way out of the egg from which it is born. If we were to crack the egg and help the chick, it would die. It needs to peck its way out in order to become strong enough to survive. Strength and struggle go together. Just knowing that it is nor-

Understanding Behavior Change

By Sandra M. Christensen, MSN, ARNP

Part 1 of 2: Setting Patients Up For Success ...it takes great attention and focus to form a new neural network, which is why

there are so many lapses back to prior behav-iors when a person attempts to change a well-established pattern.

ASBP News - March & April 2011 9

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mal and important to struggle can be helpful. The explosion of neuroscience research in the past de-cades has provided us with a much richer understanding of human behavior. We are learning more about neurons and their intricate connections, as well as how these con-nections grow and are pruned throughout the lifespan. While it is beyond the scope of this article to delve into these concepts in any detail, I will extract one concept that is pertinent to this discussion. In the mid 1900s, Donald Hebb, one of the founding fathers of neuropsychology, composed the well-known Hebb’s axiom which states, “The neurons that fire togeth-er wire together.”1,2,3,4 This means that as we continue a behavior, the neurons involved wire together into a strong and intricate web. Because the brain wants to be as ef-ficient as possible, this process becomes unconscious and all one needs to do is be in a certain place, experience a particular feeling, or be with a specific person, and the brain will automatically fire that neural network. For our patients, it could mean that feeling angry can lead to eat-ing a box of cookies without them having much aware-ness of what they are doing. Their brains are essentially on autopilot. Neuroplasticity is a concept that describes the brain’s ability to be malleable or plastic, meaning that it can add or remove neural connections and grow more cells. Es-sentially, our brain is capable of being rewired2,3,4. This is the good news, and I like to share this concept with my patients. However, it takes great attention and focus to form a new neural network, which is why there are so many lapses back to prior behaviors when a person at-tempts to change a well-established pattern. If we can help our patients understand that it takes time and atten-tion for their brains to rewire, and that during times of stress they are more likely to revert to old patterns, they can learn to be more patient with themselves and make the changes that will help them improve their health and

manage their weight for the rest of their lives. Part two of this article scheduled to be published in the July/August 2011 newsletter will explore ways to help pa-tients become unstuck after they become derailed.

About the Author Sandra M. Christensen, MSN, ARNP is the owner and sole practitioner of Integrative Medical Weight Manage-ment in Seattle, Washington. In 2009 she was among the first group of nurse practitioners to take the American Board of Bariatric Medicine exam and was awarded with a Certificate of Advanced Training in Bariatric Medicine. Ms. Christensen has been an ASBP member since 2005.

References1.Cozolino,L.Theneuroscienceofpsychotherapy:Healingtheso-

cialbrain.(W.W.Norton&Company,NewYork).2010.

2.Hebb,D.O.TheOrganizationofBehavior:Aneuropsychological

theory.(Wiley,NewYork).1949.

3. Siegel, D.J. The developing mind: How relationships and the

brain interact to shapewhowe are. (Builford Publications, New

York).1999.

4.Siegel,D.J.Mindsight:Thenewscienceoftransformation.(Ran-

domHouse,NewYork).2010.

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8 ASBP News - July & August 2011

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Learning how to get back on track after becom-ing derailed is one of the most important skills

that any of us can acquire. It is a crucial part of the change process. As discussed in part one (March/April 2011 issue), it requires time, effort and attention for the neural pathways in our brains to rewire1,2,3,4. This is a difficult concept for many of us, especially perfectionists or strictly black and white thinkers. If we think we have to do everything perfectly, anything less feels like failure and results in a barrier towards making sustainable change. I find that patients who come out of the gate on track with eating and exercise and continue for weeks and months often hit a wall, and may partially or com-pletely revert to old patterns. At this point they be-come discouraged and feel like failures. So how do we help our patients get back on track when they become derailed? The most important and challenging task for health care providers is to view this event as an opportunity instead of a failure, and to convey this point to our patients. Although un-comfortable, most of my biggest learning experiences have come from making mistakes. I find that sharing this information with my patients helps them relax and remember their humanness, which helps them ease into a mindset where they can learn from their experiences. I re-cently read the following quote by writer Elbert Hubbard: “A failure is a man who has blundered but is not able to cash in on the experience5.” When derailments inevitably occur, our goal is to help our patients cash in on the experience. Many of my patients are interested in learning from their mistakes and have often thought about this before they arrive in my office. Many think that, if they can crack the code about why they de-railed, they can prevent future occurrences. Change expert MJ Ryan posits that understanding why is the booby prize, since figuring out why does not help us make desired changes6. Instead I recommend focus-ing on what happened. By examining the internal and external events that occurred before, during, and

after their derailments, patients can become more in touch with the whole experience—thoughts, feelings and body sensations. This puts them in a better posi-tion to gradually learn how to do things differently. The poem Autobiography in Five Short Chapters, written by Portia Nelson7, outlines the process of change as we progress from being unaware to very aware of ourselves and our environments. Nelson uses the analogy of falling into a hole. Chapter one talks about walking down a street and falling into a hole we did not see. We feel lost and hopeless since it takes forever to find our way out. In chapter two we walk down the same street, pretend we do not see the hole and fall in, and cannot get out for a long time. By chapter three we walk down the same street, see the hole, and fall in. We start to realize that this is a habit and get out much sooner. Chapter four explains walking down the same street and walking around the hole. In the final chapter we choose to walk down another street. I find it helpful to give my patients copies of this poem as we progress through their derailments. I tell them that the poem should actually be named Au-tobiography in One Hundred Really Long Chapters because there are numerous sections to each chapter.

Each section de-scribes slightly different levels of awareness and behaviors. By asking patients what happened in their lives when they fell off track, I can often help them locate them-selves further along the continu-

um of change than they estimated themselves to be. “I knew what I was doing, but I did it anyway,” is a common response. I am able to help them see that they are not in chapter one, but are progressing in the chapter three zone. This is often quite reassuring and helps them feel more hopeful about changing. The reality is that we need to fall in the hole over and

"By exAmiNiNg the iNterNAl ANd exterNAl eveNtS thAt occurred Before, duriNg, ANd After their derAilmeNtS, PAtieNtS cAN Become more iN touch with the whole exPerieNce — thoughtS, feeliNgS ANd Body SeNSAtioNS."

Understanding Behavior Change

By Sandra Christensen, MSN, ARNP

Part 2 of 2: How to Help Derailed Patients Get Back On TrackB

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ASBP News - July & August 2011 9

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over again, each time becoming more intimately aware of every nuance and detail before we are able to walk down another street. During this process, both the patient and the clinician need to be curious about what happens for the patient, rather than be judgmental. Learning to be kind and gen-tle with ourselves is a skill that is awkward and uncom-fortable at first, but will reap many rewards with time. For many of us, our first reaction is to berate and criticize ourselves, but doing so makes it harder to change, since we have powerful negative emotions to deal with, as well as being challenged to get back on track. When I hear patients verbally criticizing themselves, I gently point out that using the “mean voice” will only make things worse. This is often enough to redirect them to more productive self-talk. Bringing compassion to the struggle of making long term change with a chronic issue such as obesity gives patients an opportunity to learn more about the sub-tleties of their thoughts, feelings, reactions and triggers that led to their derailment. Motivational interviewing is another helpful tool. The basic concept of this technique, developed by Miller & Rollnick (2002)8, is that we are all ambivalent about making changes—even those that we desperately want to make. By identifying and exploring the positives and negatives of making the desired change, we can better understand and manage the part of us that is invested in remaining the same. Miller & Rollnick (2002) recommend an exercise wherein patients write down the costs and benefits of desired change (e.g. losing weight) and its opposite (e.g. staying the same) on a Decisional Balance Sheet. The costs of the desired change and the benefits of staying the same are rarely conscious, and they often interfere with change. By completing this exercise, patients may become more aware of any underlying issues preventing them from reaching their desired goals. When a patient seems stuck and cannot refocus, I recommend that they take a few days to complete this exercise. I remind them not to censor their thoughts and feelings, as the goal is to get at what is really inside of them, not what they think it should be. Again, self-awareness is key. We do not make our best choices when we come from a fearful place. I try to help my patients focus their ef-forts on feeling their best, as opposed to the comment, “I’m killing myself,” which I hear frequently. I encour-age them to focus on how they want to feel—physical-ly, mentally, emotionally—both now and in the future. Many patients do not feel well physically or emotionally after eating too many simple carbohydrates or not enough

protein. They suffer the ill effects of eating larger meals instead of fewer, smaller meals, or bingeing and failing to exercise. By asking “What would make you feel better?” they can identify a small change that leads them back to more healthful behaviors. Derailed patients often feel overwhelmed at the pros-pect of refocusing on their eating and exercise routines, especially when they are under stress. Instead of going global by focusing on how hard the whole process is, I ask, “What is one thing you could do differently in the next week?” and emphasize that this is the only thing they need to focus on. By breaking their goals down into manageable steps they can gradually get back on track. Hopefully, they will also internalize this skill so that eventually they will be able to do this for themselves. Long term change is a messy, error-filled process. Helping our patients navigate the ups and downs more skillfully will enable them to have the greatest chance of making sustainable change to improve their health and well-being for the rest of their lives.

About the Author Sandra M. Christensen, MSN, ARNP is the owner and sole practitioner of Integrative Medical Weight Manage-ment in Seattle, Washington. In 2009 she was among the first group of nurse practitioners to take the American Board of Bariatric Medicine exam and was awarded with a Certificate of Advanced Training in Bariatric Medicine. Ms. Christensen has been an ASBP member since 2005.

References1. Hebb, D.O. (1949). The organization of behavior: A neuropsycho-

logical theory. New York: Wiley.

2. Cozolino, L. (2010). The neuroscience of psychotherapy: Heal-

ing the social brain. New York: W.W. Norton & Company.

3. Siegel, D. J. (1999). The developing mind: How relationships

and the brain interact to shape who we are. New York: Guilford

Publications.

4. Siegel, D. J. (2010). Mindsight: The new science of transforma-

tion. New York: Random House.

5. Hubbard, E. Quotations book. Retrieved June 23, 2011, from

http://quotationsbook.com/quote/13749/#axzz1QTqyOl00

6. Ryan, M.J. (2006). This year I will: How to finally change a habit,

keep a resolution, or make a dream come true. 1st Edition. New

York: Broadway Books.

7. Nelson, P. (1993). Autobiography in five short chapters. There’s

a hole in my sidewalk: The romance of self-discovery. Hillsboro:

Beyond Words Publishing, Inc.

8. Miller, R. & Rollnick, S. (2002). Motivational interviewing: Pre-

paring people for change. 2nd Edition. New York: The Guildford

Press.